Respiratory Assessment-Review Flashcards
Suprasternal Notch
Top of the manubrium and located by the depression at the base of the neck
Xiphoid Process Topgraphy
Palpitate downwards from the glodious to the bottom of the sternum
C7 Topography
Have the pt. extend forward and down and at the base of the neck is C7
T1-T12 Topography
T1 is located right below C7
Scapulae Topography
Pt. raise arms above head
The inferior border can be identified
Sternal Angle Topography
Palpitate down from suprasternal notch until you feel the ridge that seperates manibrium and gladiolus
Midscapular Line Topography
On posterior on either side of midscapular line (left and right) located through the inferior angle of the scapula
Midaxillary Line Topography
Located on lateral chest and divides lateral chest into two equal halves
Diaphragm Topography
End of Expiration
Right: T9 posterior and the 5th rib anterior
Left: T10 posterior and the 6th rib anterior
At the inspirtory position depends on the pt. position and the force of the breath
Tracheal Bifurcation Topography
Anterior-Behind sternal angle
Posterior-T4
Superior Lung Border Topography
Anterior-2-4 cm above medial 3rd of clavicle
Posterior-Inline with T1
Gladiouslus topography
Below the sternal angle is the gladious (sternal body)
Manubrium Topography
From suprasternal notch directly below manubrium
Second Rib Topography
The 2nd rib articulates with sternal angle from here you can palpitate the rest of the ribs
Midsternal Line Topography
On anterior chest will divide chest into 2 equal halves directly down from the middle of the line
Midclavicular Topography
Left and right of the midsternal line drawn through the clavicular midpoint
Midspinal Line
On posterior chest and divides the back into 2 equal points
Directly down center of spine
Posterior Topography
Parallel midaxillary line on the posterior side
Anterior Axillary Line
Parallel midaxillary line on the anterior side
Cyantoic or Pale
Central Cyanosis: Cyanosis of the trunk or core, can be visible around the mouth and lips (mucus membrane) and indicates poor oxygenation
Peripheral Cyanosis: Also known as acrocyanosis and is cyanosis of the hands, feet, ear lobes, nose, and lips and indicates poor perfusion
Pallor can be cause by anemia
I:E Ratio
A normal I:E ratio is 1:2 or 1:2.5
When there is a severe airway obstruction there will be an increase expiratory phase
If there is a acute ariway obstruction there will be an increased inspiratory phase
Retractions
Large swings in pleural pressure can result in the sinking in of soft tissue upon inspiration
Intercostal, subcostal, or supraclavicualr (may tug at the trachea)
Pulsus Paradoxus
Palpitated pulse strength will decrease with inspiration
Seen in severe asthma
Can be secondary to negative thoracic pressure due to the increase return to the IVC and decreased systolic pressure
Hoover Signs
Inward movement of ribs cage during inspiration (instead of outward movement which is normal)
Implies a flat but functioning diaphram
Abdominal Paradoxics
Fatigue of the diaphragm in the face of increase WOB is evidenced by the abdomen sinking inwards on inspiration
Normally the abdomen will move outwards with inspiration in sync with the thorax
What Does it Mean When the Whites of the Eye are Yellow?
This is a sign of jandious, which is indicative of liver disease
The liver may result in problem return fluid to the irght side of the heart and right sided heart failure
Pursed Lip Breathing
Allows the patient to slow their expiratory phase in order to help release trapped air and provide resistane in exhalation through providing back pressure and prevent premature airway collapse
Common in COPD and may be taught to do it or may do it naturally
Nasal Flaring
External nares flare outwards during inhalation and suggests an increased WOB
Diaphoresis
Sweating
Common with acute respirtory distress, severe pain, and myocardial infarction
PERRLA
Pupil, Equal, Round, Reactive to light, Accomadation
Drooping of the eyelid signals the 3rd cranial nerve damage and is known as ptosis (early warning sigh of respirtory failure)
Mydriasis
Pupils become dilated and fixed
May be due to catecholamine, atrophine, etc
Miosis
Pinpoint pupils
Parasymathetic stimulants (ex. opiates)
Diplopia
Double vision
Nystagmus
Involuntary cyclic moveemnt of eyeball
What are we looking for in the neck
- Tracheal Position-Laryns is the easiest to palpitate and if you follow it down you can find the trachea (see if it is shifted)
- Carotid pulse
- JVP and JVD
- Lymph glands
- Thryoid size and position
- Turmour or masses
- Accessory muscle use
Tracheal Shift-Atelectasis or Lung Resection
Will reduce lung volume and trachea will shift towards the affected side
Tracheal Shift-Tension Pneumothorax, Pleural Effusion, and Lung Tumor
Trachea will move away from affected side because the excessive air/fluid/tissue will push the trachea towards unaffected side
JVD
Will be hard to see in an obese or muscular neck
Measured at the end of a full exhalation
Most common cause if right sided heart failure
Pectus Carinatum
Sternum protrudes outwards
Pectus Excavatum
Bottom edge of sternum is depressed inwards
Bifid Sternum
Congenital abnormality
Where 2 halves do not fuse together and are split
Kyphosis
Spine has a abnormal AP curvature (front to back)
Kyphoscoliosis
Combination of increase abnomal AP curvature and a lateral curvature
Barrel Chest
Increase AP diameter with a loss of normal rib slope in relation to the spine and a development of accessory muscle overuse
Common in COPD
Flail Chest
A section of the rib cage fracture due to the injury and moves freely paradoxically
Move in on inspiration and bulges on expiration
Vocal Fremitus
Vibration created by the vocal cords during phonation which are transmitted through the parenchyma to the chest wall
Bronchial obstructon (mucosal plug, forgein object) or when plaural space lining becomes filled wih air (pnemothorax) or fluid (plaural effusion) will decrease vocal fremitus (may even be absent)
Tactile Fremitus
When vibrations created by the vocal cords during phonation are felt on the chest wall
Assessment-Pt. repeats a words while the RT palpitates thorax
Increased Tactile Fremitus
Conditions that increase the density of the lung will result in a increased intensity of fremitus (lungs are more solid)
Pneumonia
Lung tumor or mass
Atelectasis (with patent bronchiole)
Decreased Tactile Fremitus
Will occur in areas of a decreased density (less solid and more air)
Unilateral-Bronchial obstruction, pneumothorax, pleural effusion
Bilateral-COPD with hyperinflation, muscular, or obese
Absent Fremitus
No ventilation
Thoracic Expansion- Assessment
Have pt. breath all the way out
Place hands on posterior of chest with thumbs at T8 midline with fingers secure on lateral sides of the chest
Note the movement of the thumbs
Normal-Thumb move 3-5 cm
Decrease Thoracic Expansion
Decreased Bilaterally-COPD, Neuromuscular disease
Descreased Unilaterally-Lobar consolidation, atelectasis, pleural effusion, pneumothorax
Chest Wall Palpitation
Chest wall skin can be palpated for condition and temperature (perfusion)
Can also be palpated to detcted air leaks from the lungs that have moved to just under the skin
Subcutaneous Emphysema
When air leaks from the lungs into subcutaneous tissue, and fine beads of air will produce a crackling sounds and senation when the chest wall is palpitated which is known as subcutaneous emphysema
Trauma (torn lungs and trachea) over distension via positive pressure ventilation
Will feel like rice krispies
Precussion
Tapping on the chest
Effect percussion produces vibration of lung to a depth of 5-7cm
Normal resonance is low and clear
Increase Resonance (Percussion)
Lower in pitch and louder than a normal drum
Occur in conditions where there is more air (hyperinflation)- COPD, asthma, pneumothorax
Decreased Resonance (Percussion)
Higher in pitch, shorter duration, and softer than normal
Occurs in conditions of increased density consolidations, tumor, atelectasis, pleural effusion, and hemothorax
Hyperesonance Resonance (Percussion)
Hollow sound
Can be in air trapping
Ex. Severe asthma attack
Diaphragmatic Excursion
The range of diaphragm movement can be estimated through percussion and assessed on the posterior chest
To assess the pt. should take a deep breath and hold it. The clinician can determine the lowest margin of resonance through percussion over the lower lung field moveing downwards in small incrememts until a change has been heard. The a pt. will do a maximum exhalation and the percussion process has been repeated
Stethoscope
Bell-Used for low pitch sounds
Diaphragm-High pitch sounds
To perform an asculatation have the pt. take a deep breath with their mouth open and pt. sittign up
4 Charateristics of Breaths Sounds
- Pitch
- Amplitude
- Distinctiveness
Tracheal Breaths Sounds
Normal to be heard over the tracheal area
High pitche and loud (harsh)
Expiratory slightly louder than inspiratory
Bronchovesicular Breath Sounds
Normal in the upper 1/2 of the sternum in the front and between the scapula on the back
Medium in pitch and loudness
E=I
Vesicular Breath Sounds
Normal in the lung periphery
lowest pitch and quiestest sound
mostly I with minimal E
Adventitious Sounds Can be Described As:
Continuous: Longer than 25 sec (wheeze, stridor)
Discontinuous: Intermittent, short duration, less than 20 sec (crackles, rubs)
Bronchial Breath Sounds: Considered abnormal when in areas when vesicular breath sounds should be heard instead sound tracheal
Wheezes
Musical notes generated by vibrations of narrowed airways as air passes through at a high velocity
Low pitched wheezes can be cause by sputum in the airway and can disspear with a cough
Diameter of the airway is reduced-Bronchospasm, mucosal edema or obstruction
Pitch of wheeze is affected by the diameter.
Narrow/More Compressed airway=higher pitch (will not disappear with a cough)
A louder wheeze is good because is means that air is moveing
If the wheeze is heard loudest over the neck it means that the upper airway is the source of the obsruction
Wheeze-Polyphonic
Limited to exhalation
Several muscial notes
Indicative of multiple airway involvement
Wheeze-Monophonic
Single musical note indicating single bronchus obstruction
Can be on I or E
Stridor
Continuous sound heard on inhalation
Occurs durign an upper airway obstruction
Loud and high pitched
Can be heard without a scope
Crackles
Caused by movement of excessive secretions/fluid in the airway as air passes through a collapsed airway/popping open
Discontinuous
Coarse Crackles
Also called rhonchi
May sound wet
Heard on I and E
May or may not clear with a cough
Early Inspiratory Crackles
The longer more proximal bronchi may close during expiration, and when there is a abnormal increase in bronchial compliance
Ex. COPD
These crackles tend to be few in number and can be loud or faint
Often transmitted by the mouth and not silenced through a cough or change in position
Late Inspiratory Crackles
Peripheral alveoli and airway close during exhalation when surronding intrathoracic pressure increases. The sudden openign of the peripheral airway will produce crackles
More common in dependant region of the lung due to gravitational stress predipositioning the pheripheral airway to collapse at exhalation
Recurrent rhythm
May clear with posture change or inspiratory manuvers
Cough or max exhalation may reporduce these crackles
Ex. Disease the reduce lung volume such as pulmonary edema, atelectasis, pneumonia, fibrosis
Pleural Friction Rub
Creakign or grinding sound
occur when irritated inflamed pleural surfaces rub together on I and E
Gets louder with deep breathing
May be very painful and worsen on inspiration
Assocaited with pneumonia, TB, pleurisy, pleural effusion
Bronchophony
Blue balloons
Increased intensity and clarity of resonance
Same mechanism as vocal fremitus
Increased clarity with consolidation
Whispering Pectirutiquy
Whispered sounds (usually muffled and quiet) are louder
Increased clarity with consolidation
Egophony
Nasal e-e-e soudn which sounds like a-a-a
Compressed lung above pleural effusion
Point of Maximal Impact
Also known as systolic thrust
Location-Midclavicular in the 5th intercostal space
Factor for shifts-Will shift in the same direction as tracheal shift, towards affected side of lung collapse, away from affect side in pneumothorax, will be shifted to the right closer to the gut in emphysema
Normal Heart Sounds
S1-Lubb, closure of AV Valve (mitral and tricuspid), correspond with onset of systole, louder than S2 at apex
S2-Dubb, closure of semilunar vlaves (aortic and pulmonic) beginning of ventricular diastole, louder at bases
S3
Heard after S2
Occur in early distole during rapid ventricular filling
Also known as ventricular gallop
Normal in children and yong adults due to an increase in diastolic volume
Observed in CAD, cardiomyopathies, incompenetent valves (murmurs)
Split S2/ P2
Louder valve closure or valve does not close
Caued by pulmonary hypotension
S4
Heard just before S1, late diastole, occur during atrial contraction
Also known as atrial gallop
Normal in children
Adnormal with hypotension, aortic stenosis, LV MI
There is also a murmur and gallops that are due to diseases or structural defects
Heart Sounds can also be muffled in -Cardiac tamponade, pneumothorax, obesity, pneumopericardium
Acites
Serous fluid in the peritoneal cavity due to heart failure, renal failure, liver failure (cirrhosis), and sodium retentsion
Flui imbalance issue
Increase size of right upper quadrant
Heptomagaly due to right sided heart failure
Clubbing
Painless enlarge of distal phalanges
Ex. Congenital heart disease, cyanotic, brochogenic, carcinoma, COPD, cycstic fibrosis, bronchiectasis
Unknown mechanism
Cyanosis
Occurs when more than 5.0 g/dL of reduced Hgb exists
Intensity of cyanosis increases with Hbg
Polycythemia
Polycythemoa shows cyanosis at a lesser degree of tissue hypoxemia
Will see signs of cyanosis at a high O2 saturation compared to anemic pt.
Anemia
Anemia will not show sugns of cyanosis until severe tissue hypoxemia exists
Pt. will have less RBC so there will be a lower O2 saturation level (~50%) before you see signs of hypoxia
Normal Hemoglobin Levels
15g/dL
or 150 g/L
Pedal Edema
Accumulation of fluid in ankles due to right sided heart failure
Pitting Edema
When clinican presses upon ankle making an indentation and remains there for a while
Peripheral Skin Temperature
Cool skin temperature can indicate decreased peripheral perfusion due to vasoconstriction or poor cardiac output
Biot’s
Irregular breathing pattern with periods of apnea
Cheyne-Strokes Breathing
Breath change in dpeth with periods of apnea
Ex. Congestive heart failure
Kussmaul Breathing
Deep and fast
Can be due to metabolic acidosis
Primary Muscle of Ventilation
Diaphragm and Intercostal Muscles
Ment tend to breath with diagraph and women tend to breath with intercostal muscles and diagphram
Respiratory Alternans
Periods of breathing using only chest wall followed by diaphram breathing
Diaphram fatigue
Accessory Muscles
Inspiration-Scalene, sternocleidomastoid, external intercostal
Expiration-Internal intercostals, abdominal
